POST 00765E : MEASLES CAMPAIGN AND ITN DISTRIBUTION
Follow-up on Post 00763E
20 March 2005
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It is advised to read the joint WHO-UNICEF statement on the topic at
: http://www.rbm.who.int/docs/RBM-EPI-EN.pdf
This posting contains two contributions. First that of Mark Grabowsky
(mailto:[email protected]) from the American Red Cross. We draw
your attention that Mark has published, with ten other colleagues an
article on the topic, "Distributing insecticide-treated bednets during
measles vaccination: a low-cost means of achieving high and equitable
coverage". The abstract can be found at :
http://www.who.int/bulletin/volumes/83/3/grabowsky0305abstract/en/
and the full text in the Bulletin of WHO (March 2005), at :
http://www.who.int/bulletin/volumes/83/3/en/195.pdf
The second contribution comes from Robert Steinglass
(mailto:[email protected]) of the Immunization Basics project of
the United States, reacting to the first.
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1. The debate on "campaigns versus routine" will end up for ITNs where it
ended up for vaccinations - both have a role to play based on program goals
and epidemiologic setting. The debate on "free versus paid" echoes those of
the Bamako initiative which argued that sustainability required "user
fees." In the end, if a service was a public health good - like
immunization - then society was better off it was free to consumers
(leading to simpler management, higher coverage and greater equity). The
sustainability issue then came down to how much was paid for by government
versus donors. Even if government found donors willing to pay for 100%, it
was deemed sustainable. Some of the vaccines that are routinely given for
free cost more than ITNs (e.g., Pentavalent DPT-Hib-HepB or Pnmeumococcal).
2. Mass, free distribution, compared to social marketing, achieves higher,
quicker, and more equitable coverage at lower cost to both consumers and
providers. In each measles/ITN campaigns (Ghana/Zambia/Togo), coverage has
risen from 80% with equal coverage among all wealth groups. The
marginal cost per ITN delivered was about $0.50. That is a fraction of the
cost required to run a social marketing program. Giving nets away is
cheaper for both the consumer and the provider.
3. The title of the email is provocative, "What do malaria experts have to
say . . . ." Here is what some published experts say: "Rather than
subsidizing marketing systems, we urge that new funding would be better
targeted at organized provision of ITNs and their retreatment so that cost
to those suffering from malaria is not a limiting factor in attaining high
coverage rates." (Christopher Curtis, Caroline Maxwell, Martha Lemnge,
Richard W Steketee, William A Hawley, Yves Bergevin, Carlos C Campbell,
Jeffrey Sachs, et al Lancet Infectious Diseases 2003;3:304-7.)
4. What does the UN Millennium Project have to say about this approach and
achieving the MDGS: "Developed and developing countries should jointly
launch, in 2005, a group of Quick Win actions to save and improve millions
of lives and to promote economic growth. The Quick Wins include but are not
limited to: Free mass distribution of malaria bed-nets and effective
antimalaria medicines for all children in regions of malaria transmission
by the end of 2007."
(http://unmp.forumone.com/eng_html_07.html)
5. The fundamental reason to support mass, free distribution is that the
evidence suggests that it is the best way to deliver services to the poor.
In most countries of sub-Saharan Africa, about 75% of the population lives
in poverty
(See, for example: http://poverty.worldbank.org/library/view/8717/).
Are we against giving free nets to the poorest 76% so that we can preserve
the rights of the wealthier 24% to buy subsidized nets? There will always
be a place for those who want to provide efficient market-based mechanisms
to serve the relatively wealthy but should we
use public or donor funds to support this in preference to more efficient
systems for delivering services to the poor?
Mark Grabowsky, MD, MPH
CDC Technical Advisor
American Red Cross
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Mark,
Plenty of stuff to chew on. I am glad you took the bait. I hope that more
people will join in the debate, especially malaria staff with a long-term
developmental view. It would be good to hear their views.
Campaigns certainly have a roll to play but their harmful effects must be
minimized: Advocates should cease exaggerating what campaigns are going to
contribute to strengthening the routine services! The fact that simple
measures of accountability (vis a vis the routine program) are not accepted
by campaigners, even as they claim that support for campaigns will indeed
strengthen the routine program (thereby placating potential donors who have
some concerns), is telling.
At every TFI meeting and measles partnership meeting where it has been
proposed, there has been resistance to accept adoption of, tracking and
reporting on indicators -- e.g., including DTP3 coverage - - of routine
immunization performance AS AN INTEGRAL PART OF ACCELERATED DISEASE CONTROL
INITIATIVES. Given that the vast amount of resources that are mobilized
these days are spent on accelerated disease control, and that these
initiatives persist in claiming that routine immunization is the
all-important foundation that the campaigns are indeed helping to
strengthen, then indicators are an obvious necessity. Do you agree or not
that as part of accelerated disease control initiatives, indicators for
routine immunization performance - e.g., including DTP3 coverage - - should
be formally adopted, tracked and reported?
Robert
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